Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression, if that is being considered, and it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use), and duloxetine (because of limited data in children and adolescents). It is important to consider a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So for example if considering fluoxetine, a starting dose of 10mg qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.

PMDD symptoms includes moderate to severe depressed mood, irritability, mood lability, anxiety, anger, difficulty concentrating, and insomnia that occur exclusively in the two weeks before menses and cause significant impairment in daily functioning. PMDD is distinguished from other psychiatric disorders by timing; patients have symptoms only during the luteal phase of the menstrual cycle and report normal mood during the follicular phase. On average, symptoms last 6 days and peak 2 days before menses.

In patients who take oral contraceptive pills (OCPs), it is important to assess if symptoms are present and as severe even when they are not taking the OCPs, to eliminate the possibility that the symptoms are a side effect of the OCPs.  Patients with PMS and PMDD profiles should also be screened for co-morbid mood and anxiety disorders with symptoms present throughout the month. It is also important to screen PMDD patients for abuse histories, as there is a high correlation and referral for psychosocial intervention may be indicated.

To help distinguish between PMDD and PMS, patients can keep a daily mood diary for at least 2 months. The Daily Record of Severity of Problems (http://pmdd.factsforhealth.org/drsp/drsp_month.pdf) is a useful tool.

There are a variety of treatment options for PMDD. Antidepressants that exclusively affect serotonergic transmission (citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, and clomipramine) are effective and can be used on an on-off schedule during the luteal phase because they have a rapid onset of action compared to antidepressant effects for depression. The use of combined oral contraception (estrogen and progestin) is common and more effective than either alone. Drospirenone/ethinyl estradiol is FDA-approved for PMDD. GnRH agonists have been found to be helpful but have problematic side effects, including medical menopause. Non-medication approaches that show some promise includes bright light therapy, calcium supplementation and chasteberry.

PMDD is a serious mental health concern that can lead to significant impairment for those affected. It is important to have the tools to assess for this disorder and offer appropriate treatment when indicated.